Benefits Plans and Coverage Flashcards

Out-of-pocket costs that do NOT count toward a member's out-of-pocket maximum typically include:

Answer: Premiums and balance billing from out-of-network providers

Premiums and balance billing charges from out-of-network providers generally do not count toward the ACA-defined out-of-pocket maximum.

What is a grandfathered health plan under the ACA?

Answer: A plan in existence on March 23, 2010 that hasn't made significant changes

A grandfathered plan existed on the ACA's enactment date (March 23, 2010) and has not made significant changes that would cause it to lose grandfathered status.

In a family health plan, an embedded deductible means:

Answer: Each family member has their own individual deductible within the family deductible

An embedded deductible means each family member has an individual deductible limit so that one person's costs can trigger coverage before the family aggregate is met.

Which of the following is NOT typically considered a qualified medical expense for an HSA?

Answer: Health insurance premiums (most circumstances)

HSA funds generally cannot be used tax-free to pay health insurance premiums, with limited exceptions such as COBRA or long-term care premiums.

When an FSA is described as 'use it or lose it,' this refers to:

Answer: The requirement to spend FSA funds within the plan year or forfeit unused amounts

FSA funds are subject to a 'use it or lose it' rule, meaning unused balances at year-end are forfeited unless the plan offers a grace period or rollover option.

What is the primary difference between a copayment and coinsurance?

Answer: A copayment is a fixed dollar amount; coinsurance is a percentage of the allowed amount

A copayment is a set dollar amount (e.g., $30 per visit), while coinsurance is a percentage of the allowed cost that the member pays after the deductible is met.